Fillable form accident

Sample Employee s Report of Injury Form Instructions Employees shall use this form to report all work related injuries illnesses or near miss events which could have caused an injury or illness no matter how minor. Continue on the back if necessary What could have been done to prevent this injury/near miss What parts of your body were injured If a near miss how could you have been hurt Did you see a doctor about this injury/illness If yes whom did you see Doctor s phone number Date Has this part of your body been injured before If yes when Time Your signature Supervisor s Accident Investigation Form Name of Injured Person Date of Birth Telephone Number Address City Circle one Male State Zip Female What part of the body was injured...